New Patients (Adult)
Patient Information
Patient Name
*
First Name
Last Name
Nickname (if preferred)
Gender
Male
Female
Your date of birth
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone/Cell
*
-
Area Code
Phone Number
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Employer
How did you hear about our office?
Have we treated another member of your family?
Yes
No
What are the main endodontic concerns that you would like to be accomplished?
What is the name of your dental insurance and subscriber ID?
CLOSEST RELATIVE
Name
Mr.
Mrs.
Ms.
Miss.
Dr.
Other
Prefix
First Name
Middle Name
Last Name
Relationship to patient
Cell Phone
-
Area Code
Phone Number
Dental & Medical History
Name of General Dentist
Last Visit with Dentist
Have you taken a X-ray within the last 12 months?
Yes
No
If yes, do you have a digital copy?
Name of Primary Care Physician
Are you taking any blood thinners?
*
Yes
No
Have you taken any IV Biphosphate in the past 15 years?
*
Yes
No
Patient's Pharmacy Name
Patient's Pharmacy Address and Phone Number
Are you currently under the care of a physician?
*
Yes
No
If 'Yes' please explain
History of Major Illness?
*
Yes
No
If 'Yes' please explain
Any allergies?
*
Yes
No
If 'Yes' please explain
Currently taking any medications?
*
Yes
No
If 'Yes' please explain
Do you require antibiotics before dental treatment?
*
Yes
No
Have there ever been injuries to your face, mouth or chin?
*
Yes
No
Have you ever had pain/tenderness in your jaw joint (TMJ/TMD)?
*
Yes
No
Please Add medical conditions here
Birth defects or hereditary problems
*
Yes
No
Bone fractures, or major injuries
*
Yes
No
Any injuries to face, head neck
*
Yes
No
Arthritis or joint problems
*
Yes
No
Diabetes or low sugar
*
Yes
No
Kidney problems
*
Yes
No
Cancer, tumor, radiation treatment or chemotherapy
*
Yes
No
Stomach ulcer, hyperacidity, acid reflux
*
Yes
No
Immune system problems
*
Yes
No
History of osteoporosis
*
Yes
No
Gonorrhea, syphilis, herpes, sexually transmitted diseases
*
Yes
No
AIDS or HIV positive
*
Yes
No
Hepatitis, jaundice, or other liver problems
*
Yes
No
Polio, mononucleosis, tuberculosis, pneumonia
*
Yes
No
Seizures, fainting spells, neurologic problem
*
Yes
No
Mental health disturbance or depression
*
Yes
No
Vision, hearing or speech problems
*
Yes
No
History of eating disorder (anorexia, bulimia)
*
Yes
No
High or low blood pressure
*
Yes
No
Excessive bleeding or bruising, anemia
*
Yes
No
Chest pain, shortness of breath, tired easily, swollen ankles
*
Yes
No
Heart defects, heart murmur, rheumatic heart disease
*
Yes
No
Angina, arteriosclerosis, stroke or heart attack
*
Yes
No
Skin disorder (other than common acne)
*
Yes
No
Frequent headaches or migraines
*
Yes
No
Frequent ear infections, colds, throat infections
*
Yes
No
Asthma, sinus problems, hayfever
*
Yes
No
Do you frequently breathe through your mouth
*
Yes
No
Do you chew or smoke tobacco?
Yes
No
Women: Are you pregnant?
Yes
No
Are you trying to become pregnant?
Yes
No
Please list any other condition that you want us to be aware of:
Do you give the office of Dr. Keivan Zoufan DDS. permission to send your records (X-ray and photos) to your dentist?
*
Yes
No
Please agree to the following
*
I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child’s medical status. I hereby authorize release of any information related to insurance claim. I consent to examination by the doctor and I authorize payment of any insurance benefits to the office.
Patient's Signature
*
Clear
Submit
Should be Empty: